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Monday, 13 March 2017

A Forgotten Episode of International Health by Dora Vargha

In this month's blog post, Dr Dora Vargha, University of Exeter, uncovers the neglectedrole of the Socialist Bloc and Eastern Europe in the history international public health. Dora argues that rectifying this omission is essential to capture a complete picture of international and global public health in the crucial era following the postwar settlement.

The Establishment of the World Health Organization

The establishment of the World Health Organization is no doubt a crucial and fundamental moment in the history of international (and global) public health. The leadership, ideas and early decades in the unfolding Cold War can be assembled through biographies of Director-Generals, the Organizations own chronicle of its first decades and through histories of malaria eradication. However, certain equally important aspects of the early years of the WHO, like the sudden exit of the Soviet Union and Eastern Europe shortly after the establishment of the organization merit little more than a mention in these histories.

The Socialist Bloc and the Missing History of the WHO

Andrija
Stampar (1888-1958), born in Drenovac, Croatia,
was a key figure in the history of twentieth-century public
health and a leading figure in the League of Nations Health
Organisation. Commemorative Stamp of Anrija Stampar,
issued 1970, Yugoslavia (Public Domain).

This omission from the historiography is not entirely surprising. The Socialist Bloc, and Eastern Europe in general has been, until recently, missing from international health narratives on the whole, despite foundational Eastern European figures in its history such as Andrija Stampar, key member of the League of Nations Health Organization (LNHO) and president of the First World Health Assembly, and Ludwik Rajchman, director of the LNHO and founder of UNICEF. Often seen as a politically homogeneous area under complete Soviet control in the postwar era, Eastern European countries have not been considered to have agency in international health during the Cold War.

But the history of international and global health has a lot to gain by including the Socialist Bloc in the picture. This unexplored history points to questions whether international health always happens within organizational structures of international agencies and through philanthropic entities such as the Rockefeller Foundation; what the stakes were in this Cold War divide in the formative years of the WHO; and the extent to which we can talk about a unified response within the Socialist Bloc to diplomatic and public health challenges in their time outside of the organization.

Through the lens of Hungary, the last country to re-join the WHO in 1963, my research aims to put Eastern Europe in the focus of international health inside and out of the World Health Organization. I seek to explore what happened to international health in Eastern Europe, outside of the purview of the usual suspects: international agencies and non-governmental organizations, like the Rockefeller Foundation, how complete was the break with liberal internationalism and what, if anything, took its place.

It was not long after Eastern European states successfully joined that the Soviet Union decided to leave the WHO. The Russians were not very eloquent in their reasoning, they cited the mammoth bureaucracy, high member fees and the political influence of the United States in the WHO. The exit of the Soviet Union, followed by the whole Socialist Bloc challenged the proclaimed universality of the newly formed WHO and the centrality of technical expertise in opposition to political allegiance. The quick deterioration of the East’s relationship with the organization seems to fit neatly into a narrative of the escalating Cold War and increase of the Soviet Union’s hold on Eastern Europe. However, when inspected in detail, the reasons for the exit of these countries was more complex and had to do as much with expectations of what an international health agency should do, as with foreign policy.

The grievances towards the WHO had been many and from an Eastern European perspective, were mostly justified. The overpowering American influence undoubtedly played a large role in this. Certain issues, such as Americans barring access to vital drugs, such as penicillin in Poland and Czechoslovakia, became especially sore points for Eastern European politicians and physicians. In his memoir from 1978, Tibor Bakács, Hungarian virologist and representative to the second World Health Assembly in 1949 gave a dramatic account of the appeal of Josef Plojhar, Czechoslovak health minister and roman catholic priest.

Socialist countries did not have their own penicillin plants back then, they had to import the needed amount for hard currency from the West. The Czechs, in order to become independent, purchased a whole penicillin plant from the Americans before the political turn of February 1948, which according to the contract the US had to deliver in two installments. The first one arrived, but the second one, which was to be delivered after the political turn, was held back by the Americans. Father Plojhar, wearing priest’s attire, asked the delegation of the United States in front of the Assembly, why they had not honored the contract. The American delegate, putting aside all civility (and with the knowledge of the subservient voting machines behind its back) just briefly said: "Contract, no contract, you turned socialist, you get nothing!" The president of the assembly then put the Czechoslovak question to vote, and apart from the 5 yes votes of the socialist countries present, the issue was overruled by the majority. The vassals "voted well" - it was a real American decision. I wouldn’t have thought that professional issues, what’s more, questions of health can be distorted so under political duress.1

While Plojhar’s speech does not appear in the minutes, the American delegate, Leonard A. Scheele Surgeon General referred to it and dismissed the claim by stating that the equipment in question is not necessary for the production.

Attributing Eastern European countries’ decision to leave solely to Cold War political alignments would be a mistake, however. Recent research on the years of communist takeover has shown that the relationship of the Soviet Union and Eastern European countries was a complex one and certain aspects of that relationship were very much open ended. We cannot readily assume a master plan from the Soviet side, with which Eastern European states quickly fell in line with. Moreover, while the overwhelming influence of the United States in the WHO and pressure from the Soviet Union no doubt playing an important part, countries like Hungary had other, substantial reasons for discontentment.

Second World Health Assembly

The Socialist Bloc did not immediately follow the Soviet Union in stepping out of the WHO. The minutes of the second World Health Assembly in 1949 give a glimpse of the short time when Eastern European countries took part in the WHO’s work without the presence of the Soviet Union in the organization. In their speeches, Eastern European delegates acknowledged the merits of the WHO and the overall significance of the organization.

However, there were problems: several Eastern European delegates criticised the WHO for its one size fits all approach. Apart from issues with access to penicillin, the Czechoslovak delegate called on the WHA to rethink the universality of certain public health issues and instead, consider health priorities on a national level. The Hungarian Health Minister, István Simonovits pointed to the fact that while Hungary considers fellowships to be crucial as a form of pursuing international public health, many of its fellows are regularly denied entry visas to WHO member states and are therefore unable to attend conferences they are invited to. Simonovits also considered visiting lecturers to be less useful for Hungarian public health: “Even the best lecturer was hardly more useful than a good article, because in many cases the lecturer had no knowledge of our special local problems.”

The criticism of several of the Eastern European delegates point to a different expectation of the tasks and responsibilities of international health organizations. In the late 1940s the countries in question were still in a horrid state, their hospitals bombed, medical equipment seized or destroyed, with extreme housing problems and crumbling infrastructure. In countries with extreme shortages of medication, physicians and buildings fit to house patients, and with no access to the Marshall Plan or other forms of aid, the policy of the WHO to give technical assistance instead of material aid seemed pointless, offensive even. As Plojhar, the Czechoslovak delegate put it: "It is more urgent for us to dispose of some public-health problems than to receive good advice."

Withdrawal from the WHO

The second World Health Assembly was the last one that Eastern European countries attended for almost a decade. Romania, Albania, Poland, Czechoslovakia and Hungary left the organization in 1950. Some of the delegates, like Plojhar warned of this possibility at the Second WHA in 1949. But perhaps the withdrawal was not a clear choice. Instead of issuing a warning, the Hungarian delegate used his speech to plead for the inclusion of socialist approaches to public health, and to remedy the situation that caused the Soviet Union to leave the organization.

The withdrawal of such a substantial number of countries from the WHO placed the question of membership into focus and pointed to broader questions of supranationality and state sovereignty. The WHO navigated its practice among two legal school of thoughts: one of which considers such an international organization to be supranational, making a unilateral withdrawal impossible once a member voluntarily joined, and another considering membership in the international organization to be dependent on its alignment with foreign policy. The United States favoured the latter interpretation, its Congress upholding the right to withdraw within a year of joining the WHO. The organization itself adopted a position of compromise between the two schools, introducing “inactive membership” for withdrawing states. This latter solution also helped save the international organization some embarrassment, when the Soviet Bloc exited the WHO.

Not only did the practice of international public health in Eastern Europe continue with the budding socialist internationalism within the Bloc, but countries like Hungary continued to participate through interaction and collaboration with the West. Being out of the WHO, divided by the Iron Curtain also did not mean that the region was isolated in terms of international health. If we shift our focus from viewing internationalism in public health from the perspective of international organizations and governments, and turn to the agents of internationalism themselves, we find that the sites of international collaboration in public health were as varied as the people acting as internationalists. Families and virologists, hospital directors and religious scholars were actively involved in shaping international collaboration in research, treatment and access to technology.

Decentering Narratives of Internationalism and Global Public Health

Geographically and conceptually de-centring narratives of internationalism and global public health, especially ones tied to the Cold War, is crucial for a nuanced understanding of this formative era. By bringing Eastern Europe into the focus and considering alternative internationalisms, new faces, practices and relationships become visible, which, in the end, can help us piece together a very messy and often confusing picture of international and global health in the 20th century.

Dora Vargha

Dr Dora Vargha

Dr Dora Vargha is a lecturer in the Medical Humanities at the University of Exeter. Previously, she has held research fellowship positions at the Max Planck Institute for the History of Science, Berlin and at Birkbeck, University of London. She is an acclaimed authority on the history of global health and biomedical research in the Cold War era with a particular focus on Eastern Europe. Dora's work has been widely published in leading peer-reviewed journals including Contemporary European History, and Bulletin of the History of Medicine. She has recently completed the manuscript for her forthcoming monograph Iron Curtain, Iron Lungs: Governing Polio in the Cold War which explores a series of polio epidemics in Hungary in the context of international Cold War politics. She has recently embarked upon a new research project, for which she received a Wellcome Trust Seed Award, titled, 'Socialist Medicine: An Alternative Global Health History'.